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S*Joaquin County Public Health Servos <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the <br /> generator or parent organization has on file one of the following: <br /> 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- Information Document if the generator or parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> O New (5 Renewal <br /> Medical Office/Business Name: <br /> CAKE CALLS HOME HEALTH, INC <br /> Medical Office/Business Address: 1803 W. MARCH LANE SUITE C <br /> City: STOCRTON State: CA Zip Code: 95207 —6830 <br /> Contact Person: VIVIAN RODERICK, RN Phone#:, 209 475 <br /> Storage Facility Name: INTERGRATED ENVIRONMANTAL SYSTEMS <br /> Storage Facility Address: 499 HIGH ST. <br /> City: OAKLAND State: CA Zip Coder <br /> Permitted Treatment Facility Name: erloa;-e <br /> Permitted Treatment Facility Address: <br /> City: State: Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. if not enough space, attach infoonation. <br /> 1- Name: SEE ATTACHED LIST Title: <br /> 2- Name: Title: <br /> 3- Name: Title: <br /> A copy of this exemption and a tracking document shall be In employee's possession at all times while transporting m#dlcal waste. in <br /> addition, all copies of medical waste records shall be kept on rile at generator's or health care professional's facility. <br /> Applicant Sig to <br /> Title: Date: <br /> Do Not Write Below This Line , <br /> R.E.H.S. Application Approval: Date: / / Expiration Date: <br /> EH4so2 10-03-96 Date Paid '= / /? Y Cash ori Ce k ii{ (circle) Acct '�°� <br />